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CLIENT INFORMATION PROFILE FORM
First Name:
Last Name:
Home Address 1:
Home Address 2:
City:
State: Zip:
Home Phone:
Cell Phone:
Work Phone:
Email Address:
Preferred Method of Contact:
Home Phone
Cell Phone
Work Phone
Email
FAMILY MEMBER INFORMATION
Family Member's Names:
Pets:
OTHER INFORMATION
How Did You Hear About Us?
Website
Referral
Advertisement
Mailing
Other
I Am Most Interested in:
Errand Service
Personal Shopping
Event Planning
Other
I / We:
Travel Frequently
Entertain Frequently
Need Someone to Coordinate Various Aspects of Life
I May Need Give Me A Break's Services Approximately:
Occasionally
1-4 Hours / Month
4-8 Hours / Month
8-12 Hours/ Month
14+ Hours/ Month
Preferred Method of Payment
Cash
Credit Card
Pay by Check
Please Add Any Comments / Questions / Concerns
(Please Give Us 24hs to Respond. Thank You)
 
 
 
Contact Us Today!
 
For Our Services please "Ring the Bell!"
 
 
Give Me A Break
Concierge & Personal Assistant Services
 (877) 369-2575
 
    13+ Yrs Servicing Customers                   Bonded & Insured                 Certified Nursing Assistant 
Give Me a Break Concierge & Personal Assistant Services
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11347 Red Finch Lane
Charlotte , NC , 28214 USA
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Phone 8773692575